Background

Leprosy, also known as Hansen’s disease, is one of the oldest known human diseases, dating back to ancient civilizations. It primarily affects the nerves, skin, and mucous membranes, leading to disfiguring skin sores, loss of sensation, and nerve damage. It has affected millions of people throughout history and has posed significant socio-cultural challenges due to its disfiguring symptoms and the associated stigma. The causative agent of leprosy, Mycobacterium leprae, was first identified by Gerhard Armauer Hansen in 1873 using microscope observations of bacteria in skin biopsies of leprosy patients [1, 2]. It primarily spreads by droplets that are emitted from the nose and mouth during breathing; its transmission is at a high level with patients who are infectious yet untreated. In contrast to other illnesses with a high mortality rate, leprosy is a chronic illness that slowly worsens over time and sometimes leaves behind residual disability. It is estimated that 3–4 million people are living with visible impairments or deformities due to leprosy [3]. Skin lesions, loss of sensation, nerve damage, muscle weakness, and deformities are common characteristics of leprosy. Since then, various diagnostic methods have been developed to identify leprosy, including slit-skin smears, histopathology, and molecular techniques such as polymerase chain reaction (PCR). These methods have enhanced our understanding of leprosy and improved early diagnosis and treatment outcomes, contributing to the control of the disease worldwide [1, 2].

The diagnosis of leprosy in current practice is based on the presence of at least one of the three cardinal signs: (i) definite loss of sensation in a pale (hypopigmented) or reddish skin patch; (ii) thickened or enlarged peripheral nerve with loss of sensation and/or weakness of the muscles supplied by that nerve; or (iii) presence of acid-fast bacilli in a slit-skin smear. Slit-skin smears are positive only in MB leprosy (i.e. any positive slit skin smear is classified as MB irrespective of the number of patches and/or nerve involvement) [4].

According to the WHO classification, leprosy patients are categorized depending on the number of leprosy skin lesions and nerve involvement. The classification also helps on choosing the treatment regimen and predicts the future risk of complication: Paucibacillary (PB) Leprosy (a) One to five leprosy skin lesions, (b) Only one nerve trunk enlarged. Multibacillary (MB) Leprosy (a) Six or more skin lesions, (b) Less than six skinlesions, which have a positive slit skin, smear result or if there is involvement (enlargement) of more than one nerve. Additionally, leprosy patients that are difficult to categorize should be considered multi-bacillary cases and handled as such. Pure neural leprosy patients should also be categorized and managed as MB cases [5]

Leprosy was vertically treated in Ethiopia’s healthcare system until 2001 at hospitals with a focus on the disease. By the end of 2001, the leprosy control program had been effectively incorporated into the provision of general healthcare services, ensuring that patients receive an early diagnosis and successfully complete the multidrug course (MDT) with no concomitant disability [6].

Due to the chronic impairment and social stigma it causes, leprosy has been a concern for public health for many centuries. Early detection and prompt treatment with multidrug therapy (MDT), the basic tenets of leprosy control, led to a significant reduction in the burden of leprosy by the early 2000s. During 2021, 140 594 new cases were reported globally, for a case detection rate of 17.83 per million population. The rate of detection of new cases increased by 10.2% as compared with 2020 (128 405)New cases in children indicate recent transmission, and 9052 new child cases were reported globally, with a corresponding rate of 4.5 per million child population. An increase in the number of child cases (4.7%) was observed in 2021 when compared with 2020 (8642) [7]. The focus on delivering diagnostic and treatment services that are fairly dispersed, reasonably priced, easily available, acceptable, and of a high standard will continue to be a key component of leprosy control. However, the ability of health professionals to identify the early signs and symptoms of leprosy might pose a barrier to the diagnostic and treatment services [8–10].

The lack of highly specialized expertise among general health staff working in district and zonal hospitals is likely caused by the fact that the majority of these staff members were primarily focused on treating other illnesses and were therefore unmotivated to become knowledgeable about leprosy. Given that the majority of leprosy cases are seen and treated in health centers, the relatively high number of general health professionals with a positive attitude among them offers a solid potential to improve through a focus on in-service training [11].

According to the survey, most healthcare professionals were inexperienced in identifying leprosy’s early symptoms, reaction, and treatment. The vast majority of them did not know how to conduct the diagnostic voluntary muscle tests or sensory tests for leprosy.. Even though the prevalence of leprosy has significantly decreased as a result of the deployment of MDT, there are still ongoing occurrences of new cases being discovered and transmission is occurring in select highland areas of Ethiopia. One of the most significant markers of late detection in healthcare facilities, according to 2019, reported a total of 3426 leprosy cases. Among the total registered cases 2957 (86.3%) were new and 368 (10.7%) were registered as relapse [12]. The majority of the time, when cases of mb exceed 50% of new cases, they are frequently linked to a delayed diagnosis. [13]. Grade II disability which means visible deformity or impairment, of hands and feet, including claw hand, drop foot, and visible damage to hands or feet and eyes which means significantly restricts normal work, activities, or social life [14].. Prompt diagnosis and treatment of leprosy are crucial for preventing the disease’s spread as well as for avoiding negative medical and social effects and reducing the disease’s burden. The likelihood of nerve damage and subsequent disability rises as the length of the diagnostic delay; for this reason, G2D is widely used as a proxy indication for the diagnostic delay [15].

Traditional or religious beliefs about leprosy include that it is a curse from God or an ancestor, retribution from sins, or the result of witchcraft. There are several myths and misconceptions surrounding leprosy in Ethiopian culture. One prominent misconception is that leprosy can be transmitted by touch or casual contact, leading to the fear of infection among community members. This misconception has further contributed to the stigmatization and discrimination faced by individuals affected by leprosy. The stigma associated with leprosy has been sustained and increased by disability, disfigurement, and the disease’s stigma, which causes those who are afflicted to withdraw from society, hide their status, and delay receiving treatment [16, 17].

One of the major contributing factors towards the late diagnosis of leprosy is communities’ lack of knowledge regarding leprosy ultimately leading to increased likelihood of physical disability [18, 19]. The low prevalence of leprosy is associated with a fear of the loss of leprosy-specific skills within the healthcare services that could result in considerable delay in the diagnosis and treatment of the disease [20].

Early diagnosis of leprosy poses several challenges, partly due to the complex nature of the disease and the lack of specific diagnostic tools. However, advances in technology have led to the development of more sophisticated diagnostic tests that aid in the early detection of leprosy. Here are some of the challenges and the corresponding references regarding sophisticated diagnostic tests: Leprosy diagnosis depends on clinical symptoms and microscopic examination of skin smears. However, these methods lack specificity and sensitivity, especially in early cases [21]. The clinical symptoms of leprosy may take months or even years to manifest after infection, contributing to delayed diagnosis and treatment initiation [22].

Subclinical cases are individuals who are infected with M. leprae but do not exhibit any visible signs or symptoms of the disease, making early detection problematic. The availability and accessibility of sophisticated diagnostic tests, such as PCR or molecular tests, may be limited in resource-limited settings, hampering early diagnosis efforts [23]. So, a multidisciplinary team approach is crucial for early diagnosis in leprosy due to the challenges posed by sophisticated diagnostic tests. The expertise of clinicians, pathologists, microbiologists, rehabilitation specialists, social workers, counselors, and health educators ensures a comprehensive assessment, accurate diagnosis, and timely intervention. This holistic approach not only aids in early detection but also addresses the psychosocial and rehabilitative aspects of leprosy, ultimately improving patient outcomes.

A successful leprosy care and control programme within the general healthcare services at the PHC level is highly dependent upon the HWs having adequate knowledge of, and practical training on, leprosy [24]. In this light, we explored the challenge of the early diagnosis of leprosy cases by in-depth interviewing health professionals in endemic part of the country.

Methods

Results

Socio-demographic characteristics of study participants

All relevant levels of the health system—including the community level, the facility level, the district health office, the regional health bureau and others—provided participants for this study. Everybody was qualified, barring the community-level health professional and all had degrees or higher. Most of the participants had worked on initiatives connected to leprosy for more than five years. The majority of participants at the time of the interview either oversaw a leprosy-related office or directed initiatives to combat leprosy and tuberculosis. Table 1 demographic characteristics and occupational information of the participants in the study.

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Table 1. Demographic characteristics and occupational information of participants in the study.

https://doi.org/10.1371/journal.pntd.0011794.t001

Twelve key informant health workers and health extension workers interviews with in the study villages were conducted. The in-depth and key-informant interview findings were combined and organized based on the following major themes.

Discussion

This is the first qualitative study amongst health care providers related to leprosy cases in Sidama region, south Ethiopia. While leprosy health care workers agreed that level of stigma was decreasing, both groups believed that it was still possible and was associated with visible physical deformities and societal stereotypes and affected many aspects of leprosy affected persons’ lives. This study explored a variety of challenges that health professional experienced and observed during the implementation of leprosy strategies.

In this study, lack of the existence of practice-oriented training was identified as the main challenge for early detection of leprosy cases. This finding is consistent with other prior studies conducted in Ethiopia, in which almost 86% of the health workers had low-level knowledge were identified, which could be attributed to little attention given during formal training, lack of practice after training and low number of leprosy cases for practice per site [11]. The finding of this study is also comparable with a Malaysian study, HCW that reported seeing fewer cases at work were also found to have less knowledge about diagnosis and management of leprosy which reduced their ability to detect cases. The apparent lack of exposure to leprosy therefore may be a result of patients presenting with leprosy signs being missed and/or misdiagnosed by HCW than a true absence of cases in those areas. That would be a challenge in the fight against leprosy as undiagnosed cases might increase chances of disease transmission in their communities [31]. Healthcare professionals who have had leprosy training and have access to reference materials on the disease demonstrated greater knowledge and skill [32].

In this study, Integration of TB and leprosy training affects the appropriate utilization of early detection of leprosy cases. The absence of some good practice examples and the lack of efficient models from the current practice of leprosy management were all areas where the participants agreed that the integration of TB and leprosy training is not advised. Other points of the agreement included the trainers’ lack of experience with interdisciplinary planning and, implicitly, relatively superficial knowledge of the specific practice [33]. Meanwhile the ancestors of Mycobacterium leprae and Mycobacterium tuberculosis diverged from a common ancestor millions of years ago, leading to distinct evolutionary paths and differences in the diseases they cause and the body systems they affect. Leprosy primarily affects the skin, peripheral nerves, and mucous membranes. It presents in different forms ranging from tuberculoid (localized, milder) to lepromatous (widespread, severe). Tuberculosis, on the other hand,primarily affects the lungs but can also spread to multiple body systems [34, 35].

In this study lack of focus or other competing health priorities were identified as the main challenge for early detection of leprosy cases. This finding is consistent with study conducted in Ethiopia majority of health professionals focusing on treating other illnesses and being uninspired to learn more about leprosy, the general health staffs at district and Zonal hospitals lack high levels of experience [11]. Similarly other study showed that the influence of the implementation degree of the effects observed, by component, was convergent and divergent between some indicators, especially among the unsatisfactory: low proportion of contacts examined, treatment dropout, limited standardization of patient care flow, and inadequate resolution of issues with management support [36].

This study also revealed that inadequate supportive supervision of health facilities was one of the challenges of affecting the program. Similar findings were found in another study, which found that the influence of the implementation degree of the effects observed, by component, was convergent and divergent between some indicators, particularly among the unsatisfactory: low proportion of contacts examined, treatment dropout, limited standardisation of patient care flow and insufficient resolution of issues with management support [36].

The assignment of various jobs at healthcare institutions as a result of a lack of healthcare staff may result in patients receiving less attention due to overload. Due to a shortage of health workers, moving from one job to another negatively impacts the previous position held in that facility [37].

This study also revealed that Poor coordination and communications were another challenge of implementation of leprosy prevention strategies. Low attention to leprosy control initiatives is a concern in the fight against leprosy. This finding is consistent with study conducted in Ethiopia; high endemic states usually have subpar administration and a dearth of educated people [36]. Similar findings from another study show that some indicators, especially those that were unsatisfactory—a low proportion of contacts examined, treatment dropout, a limited standardisation of patient care flow and insufficient resolution of management support issues—were influenced by the degree of implementation of the effects observed by component [36].

The study explored that multiple tasks for health workers were challenging to carrying out the leprosy prevention and control program. Similar findings from another study show that the assignment of various jobs at healthcare institutions as a result of a lack of healthcare staff may result in patients receiving less attention due to overload. Due to a shortage of health workers, moving from one job to another negatively impacts the previous position held in that facility [37].

This study identified that lack of motivation among health workers and health extension workers employee disengagement and poor service quality can be caused by low morale in the workplace. Performance in work is greatly influenced by motivation. Intrinsic and extrinsic variables both inspire healthcare personnel. The effective work performance of health personnel depends on their understanding of important financial and nonfinancial motivational elements. The level of motivation in an employee affects how well the organization performs; as a result, a motivated employee is more likely to be physically healthy, mentally stable, and socially aware, which will enable them to do their jobs as required. Resources are channelled to achieve the most output from employees because managers and administrators understand what motivates people to give effective work performances [38, 39].

This study demonstrates that inadequate coordination across numerous healthcare systems, which results in barriers to care, subpar technical quality, interruptions in service, and inefficient resource usage, is one of the major challenges to achieving effective management of leprosy prevention.

Many healthcare systems throughout the world believe that one of the biggest barriers to achieving effective healthcare is a lack of coordination among healthcare levels, which causes problems with access to care, low technical quality, discontinuity of care, and inefficient resource usage [40, 41].

In this study, the importance of training related to leprosy was identified. Similarly Oman MoH regular training sessions are held for staff members at primary healthcare (PHC) and dermatology clinic levels to ensure that they have a uniform understanding of how to suspect and diagnose leprosy cases as well as to remind them of the necessity of promptly reporting leprosy cases [42]. This finding is consistent with study conducted in Ethiopia, Leprosy health education and ongoing training should be focused at the pre-service and in-service levels to support the development of health workers’ skills, knowledge and attitudes [11].

The study explore the disruption in treatment was one of the challenges that hindering the program of leprosy control. This finding is consistent with study conducted in Brazil. Poor adherence has detrimental implications such as incomplete healing, ongoing infection sources, the spread of new susceptible and antibiotic-resistant strains and the possibility of developing disability or deformity [43]. A lower defaulter rate would be made possible by health workers regularly following up and educating patients and their caregivers [44, 45].

The key strategies that recommended from the analysis of the qualitative data are as follows: The strategies include implementing and strengthening effective community awareness-building efforts, maintaining expertise in leprosy, strengthening comprehensive leprosy training for health workers, carrying out efficient and thorough contact tracing, enhancing monitoring, supervision, assessment and surveillance, boosting managerial skills, lobbying political commitment, motivating healthcare workers and health extension workers and reducing stigmatisation. These key recommendations could help in decreasing the delay in seeking health care services from appropriate institutions.

Conclusion

The study explored a wide range of possible challenges that affects the implementation of leprosy prevention and control strategies. Explored challenges might have an implication of delay of early detection of leprosy cases within the health facilities and the community in addition to the persistent nature of M. leprae in societies. These underscore the importance of taking action to avert those challenges by developing different strategies to improve the implementation of leprosy prevention and control program Therefore, health care providers improve the implementation of early detection, health education and community engagements by designing and developing appropriate strategies that should fit the local context..

As a result, health care providers enhance the implementation of early detection, health education, and community engagement by creating and implementing suitable strategies that align with the specific needs of the local community.